SHPBN-2020-007: Musculoskeletal Surgical Quality and Safety Management Program in Partnership with TurningPoint
Date: 04/08/20
Sunflower Health Plan is pleased to announce an innovative, new Musculoskeletal Surgical Quality and Safety Management Program for its KanCare (Medicaid), Ambetter (Marketplace) and Allwell (Medicare) members. The program is designed to work collaboratively with physicians to promote patient safety through the practice of high quality and cost-effective care for Sunflower members undergoing Musculoskeletal Surgical Procedures.
Program Highlights Include:
- Administrative Tools to support an efficient, user-friendly request process for obtaining medical necessity prior authorizations for procedures that require precertification. Easy and efficient post-procedural documentation submission that will be shared with Sunflower Health Plan to facilitate timely claims payment.
- Specialized “Peer to Peer” Engagement where a TurningPoint physician (from the same specialty) engages the provider regarding authorization requests that require additional clinical discussion to validate the clinical appropriateness of the procedure specific to the patient’s needs and current condition.
- Clinical Support Tools to assist in the tracking and monitoring of patient outcomes and education around patient risks and preventive measures to better coordinate care for the member and reduce infection rates and complications due to patient comorbidities.
- Reporting and Analytics that gives physicians and practice administrators greater visibility and transparency into their performance compared to the practice as a whole, as well as the rest of the market.
- FDA Recall Tracking and Monitoring to facilitate timely and consistent notification to the physician, patient, and to Sunflower Health Plan when a member has received or needs a revision surgery due to a Class I or II FDA device recall.
This correspondence serves as notice under your Participating Sunflower Health Plan Provider Agreement of these program changes, effective May 13, 2020. Physicians will be able to begin submitting requests to TurningPoint for Prior Authorization beginning on May 1, 2020, for dates of service on or after May 13, 2020. While it is the responsibility of the rendering physician to obtain prior authorization, facility providers are encouraged to contact TurningPoint to verify the prior authorization has been completed for Sunflower Health Plan members prior to admission.
Prior authorization for medical necessity and targeted length of stay (when applicable) has been delegated to TurningPoint Healthcare Solutions, LLC and will be required for the following surgical procedures in both inpatient and outpatient settings:
| Orthopedic Surgical Procedures | Spinal Surgical Procedures |
|---|---|
Including all associated partial, total and revision surgeries
| Including all associated partial, total and revision surgeries
|
TurningPoint’s Utilization Management & Precertification Contact Information:
Web Portal Intake: http://www.myturningpoint-healthcare.com
Telephonic Intake: 785-727-2483 or 877-364-5547
Facsimile Intake: 785-783-0862
Key Provisions:
- Emergency-related procedures do not require authorization.
- It is the responsibility of the ordering physician to obtain authorization.
- Providers rendering the above services should verify that the necessary authorization has been obtained; failure to do so may result in non-payment of your claims.
- Clinical policies are available by contacting TurningPoint at 785-727-2483 for access to digital copies.
Training:
Informational webinars are available! Please register at https://attendee.gotowebinar.com/rt/7321166747339046413
We appreciate your support and look forward to your cooperation in assuring that Sunflower Health Plan members receive high quality, cost-effective care for these surgical procedures.
You may search for CPT codes on our website.
We will also provide additional information and training opportunities as we get closer to the effective date of the program. If you have any questions, please contact Sunflower Health Plan Customer Service at 1-877-644-4623.